Dadu, R., Zobniw, C., & Diab, A. (2016). Managing adverse events with immune checkpoint agents. Cancer Journal, 22, 121–129. 

PURPOSE: The review focuses on the description of more common immune-related adverse events (irAEs) and provides a suggested approach for the management of specific irAEs.

 

TYPES OF PATIENTS ADDRESSED: Immune checkpoint inhibitors

PROCESS OF DEVELOPMENT: Expert opinion

 

SEARCH STRATEGY:

Dermatological toxicity (rash) is common. Risk reduction is undertaken with moisturizers; sun avoidance; avoidance of tight, rough, coarse materials next to skin; and treating skin gently. Treatment for grade 1 or 2 toxicities is topical steroids (except on face, groin, axilla, or under areas of occlusion) with oral antihistamines. Treatment for grade 3 or 4 toxicities is oral steroids.   

 

Gastrointestinal toxicities (diarrhea, colitis, obstruction, perforation) are the second most common toxicities and are dose-dependent. The workup should include a CT scan, colonoscopy, stool studies, and labs, and supportive care with intravenous fluids for hydration is advised. For mild-to-moderate (grade 1 or 2) toxicities, antimotilities are used (oral diphenoxylate HCL and atropine sulfate four times a dayand/or loperamide). If symptoms persist, oral prednisone or equivalent is used. For grade 3 or 4 toxicities, IV methylprednisolone is administered immediately. Gastroenterology consult. Infliximab produces quicker improvement in symptoms and shorter steroid treatment length. Once symptoms are resolved, steroids should be tapered over four weeks minimum. If any evidence of perforation exists, consult a surgeon and do not start antimotility agents, steroids, or infliximab.

 

For pneumonitis, seek pulmonary and ID consults. Grade 2 or greater involves hospital admission, steroids, and immune suppressants. Taper steroids over four to six weeks.